ShrinkTank and the Future

A few years ago now, a patient who was just beginning to emerge from a career of suicidally heavy drinking, interwoven with the blackest depression (derived in part from sexual abuse in his teens – but it was more complicated than that, as it always is) gathered himself for a moment and said: “I know the answers – I just wish some fucker would ask the right questions”.

There was no element of contempt, aggression or bragging in what he said or how he said it. His tone was quite neutral rather than plaintive or despondent. He seemed just to be stating the problem as he saw it and the way forward.

ShrinkTank will try to follow his lead, posing questions in a Socratic way rather than dogmatically providing answers – though there will inevitably be some slippage.  In the background there will be one awkward but inescapable truth: that in a few decades or so what we do in the field of mental health today will seem as backward and barbaric as the straitjacket, insulin coma and ice-cold douche do to us now.

Here are 20 Questions for starters.

• Will psychiatry quite soon be just another branch of physical medicine?
• Is this inevitable or can it be resisted or turned round?
• Brain and mind are coterminous (that is to say, mind stops where the brain stops) but will they soon be synonymous, meaning that phenomena or activity in the brain will be seen, not as an accompaniment to thinking, feeling and behaving but as generators of them?
• Will it eventually be possible, through chemicals or some other physical intervention, for our mood to be tweaked, for our troubling fantasies or impulses to be painlessly neutralized, or for the sting of our vices to be humanely drawn by a State-approved technician of some kind?
• Will crime, paedophilia and other perversions, excessive greed, exploitation, cruelty and so on be economically eliminated by the addition of psychotropic chemicals to the water-supply?  If fluoride, why not bromide?
• Now there is a crime gene, will there also be a terrorism gene or a robbery hormone?
• Will difference, a degree of which may be necessary for the survival of the species, be tidily managed?
• Will there be EU-agreed quotas for eccentricity, rebelliousness or subversiveness? 
• If a cure was found for the major mental illnesses, would we have to invent some more or re-designate other states of mind as abnormal?
• Would a world without madness be bearable?  Would it drive some people mad?
• If mental disorder were removed from the genome, would creativity go with it?
• Is the lexicon of mental disorder infinitely elastic? What disorders are we suffering from now that we are oblivious to because they haven’t yet been identified?
• Will the time come when being normal will be seen as being deviant and in need of treatment?
• Does increased awareness of a particular mental disorder increase the incidence of that mental disorder? To invert this, if you don’t know about bulimia, does this reduce your chances of developing bulimia?
• Does creating a construct create more cases?
• Do some drugs change brain chemistry permanently so the brain can no longer do without them?
• Is there a right to be mad?
• Is it right for the presence of mental disorder to confer absolution or diminution of responsibility?
• If culpability isn’t reduced if a person is intoxicated (because it is traced back to the decision to drink alcohol when it is generally known that alcohol impairs judgement and increases the risk of aggression), should it be reduced when someone is mentally unwell because he or she decided to stop taking medication when well (against advice and with the knowledge that medication improves judgement and reduces the risk of aggression)?
• What would a world without mental disorder be like? Does there always have to be a reservoir of abnormality? 

The good thing about questions is that they never end. On the other hand, ideology is finite, the over-arching vision sees only to the horizon.  So………

• Does stigma have a useful function?
• Why is there a hierarchy of stigma?
• How is it that some patients tend to welcome some diagnoses (post-traumatic stress disorder, bi-polar disorder, borderline personality disorder, and so on) but strongly resist others (schizophrenia, paranoia and do on)?
• Is it the small kernel of truth in paranoia which makes it so difficult to treat?
• Is “patient” a dirty word?
• Is “service user” the thin end of the wedge of marketisation?
• If we took the market out of mental health, would things get better?
• What does getting better mean?
• Is the expanding lexicon of mental disorders a response of the market to much better control of well-established disorders?
• Should mental health services and practice be the same everywhere?
• Is that possible?  If not, should computers treat? If so, what, if anything, would be lost?
• If humanity and idiosyncrasy were rinsed out of the psychiatric exchange, would that matter? If so, how much? 
• What evidence is there that the evidence-based approach works?

The problem with constructs (and campaigns, for that matter) is that thinking tends to be imprisoned inside the brackets which they create. The bad question essentially masks a statement or is camouflage for dogma and therefore has similar limitations.  The good question, on the other hand, takes you outside the confines of the construct or received wisdom. It allows you to reflect on them and to return to and revise them – or to reject them and move on.

That said, most of these questions are little peaks of ice visible here and there above the surface.  They derive from the iceberg below and out of sight – the big one, the big question – which is:

• To what extent is it possible, in this field, to establish a language and a way of relating and understanding which can remain uncolonised and uncorrupted by the marketised, technocratic, bureaucratic, biologising, digitising approach favoured by vested interests whose success and survival depend on devising vanguard brands and concepts behind which the unthinking and self-serving will obediently fall in?

I used to fantasise about wearing a bracelet which read “In the event of sudden illness and/or incapacity, I do not want to be visited by Margaret Thatcher in hospital”. Since she herself is now incapacitated, I will have engraved: “In the event of sudden illness and/or incapacity, I do not want to be the subject of a care package”.  I want, instead, to be in the company of people who have seen a lot, who think as they go along, who are happy not knowing, who do what they do because their experience tells them it works or helps not because they are implementing policy or applying procedure – though they may well come to the same thing. Humanity heals, creativity may cure; administrative approaches to mental illness and the suffering that goes with it attract staff who are cold, unengaged and incapable of establishing the kind of relationship which makes progressive change possible.